Groups Fault HHS Report on Medicaid Managed Care Providers

Medicaid groups point to methodology problems.

WASHINGTON -- A government report finding that more than half of Medicaid managed care providers weren't seeing Medicaid patients touches on an important issue but doesn't tell the full story, according to Medicaid trade groups.

The report, issued Tuesday by the Office of Inspector General (OIG) at the Department of Health and Human Services (HHS), found that 51% of Medicaid managed care providers contacted couldn't offer appointments to enrollees: 35% weren't at the location listed for them in their plan's provider directory, 8% said they weren't participating in the plan, and another 8% were not accepting new patients.

Of those who were seeing Medicaid patients, the median wait time was 2 weeks, but more than one-fourth of providers had wait times of more than 1 month, and 10% had wait times of more than 2 months, the OIG found. Specialists were more likely to offer appointments than primary care providers, but the specialists' wait times were also longer.

OIG studied the issue by getting provider data from 32 states with a total of 1.36 million Medicaid managed care providers as of January 2012. The OIG then selected a random sample of 1,800 providers, both primary care providers as well as specialists. From July 2013 through October 2013, they called all 1,800 providers and attempted to schedule appointments.

"During our calls, we asked for the earliest date available for a routine appointment with the provider," the report authors explained. "We did not provide details about any enrollee or schedule appointments. If asked, we said that we were calling on behalf of a new enrollee to determine the earliest available appointment."

Jeff Myers, president and CEO of Medicaid Health Plans of America, a trade group here for Medicaid managed care plans, said he found several problems with the report. "The report implies that because of deficiencies in directories ... Medicaid beneficiaries would not be able to get to the care they need," Myers said during a phone interview at which a public relations person was present.

He noted that each call made by the OIG was done as a "cold call" to a physician's office without an actual patient in mind. "There are a couple of issues doing it that way which may make it look bad, but it isn't the way a real Medicaid beneficiary would get access to care." Instead, most beneficiaries have access to plan call centers and to ombudsmen who would work with them to make sure they get the care they need, Myers said.

In addition, Myers noted that there was an 18-month lag from the time that the OIG got the information about what providers were in which plans to the time the researchers started calling the providers' offices. "So it would not surprise me at all if some proportion of those providers actually moved around."

However, he added, the concerns about the report's methodology "does not mean OIG hasn't raised an important issue ... We've provided some thoughts to CMS [the Centers for Medicare and Medicaid Services] about how they can look at network adequacy and some items our plans can do a little better, and I know our plans are actively thinking through how best to have a directory that has as little slippage in actual locations and dates as much as possible."

Matt Salo, executive director of the National Association of Medicaid Directors (NAMD) here, also had issues with the report.

"While network adequacy standards and wait times are important indicators, they are not always the most appropriate or useful tool to actually ensure whether Medicaid enrollees are receiving appropriate and high quality services," he said in an email to MedPage Today. "They are process measures, and states are increasingly looking at outcomes measures as means of defining success. Part of the challenge, however, is that defining and refining these real outcomes measures is still a science in its infancy and much work still needs to be done to get us where we need to be."

Salo added that NAMD is "working collaboratively with CMS and our health plan partners to identify and amplify sound practices that states can adapt to their specific program and characteristics of very diverse communities and patient populations."

Both Myers and Salo also said it isn't clear how provider access in Medicaid managed care plans stacks up to access for Medicaid enrollees using fee-for-service providers. "The challenge in the report ... is there is no way for anyone to tell with the deficiencies in managed care plans' directories -- are they [still] better than fee-for-service?" said Myers. "Are they worse than qualified health plans? I don't know how that compares to other plans."

Quality also needs to be a factor, he added. "Access to something is not the same as access to appropriate, high quality care. We're pushing the system to focus on that, and that may mean we're going to discourage access to high-cost, low value providers. I see that as a good thing, but not everyone does."

The report recommended that CMS work with states to:

Assess the number of network providers who can offer timely appointments and to improve the accuracy of plan information

Ensure that plans' networks are adequate and meet enrollees' needs

Ensure that plans are complying with existing state standards and assess whether additional standards are needed

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